Some Patients Can Choose To Be Hospitalized At Home

Chronically ill patients can receive care from home 24/7.

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ALBUQUERQUE
— TUESDAY, May 29, 2012 (Kaiser Health) —
The man's face was pasty, his eyes closed as he lay back in bed waiting for a
wave of nausea to pass. Dr. Elizabeth Ward bent over him after
checking his temperature, blood pressure, and oxygen levels and finding that
all were normal.

Physician
Elizabeth Ward, a provider with Presbyterian Health Care System's Hospital at
Home program in Albuquerque, N.M., follows up with Pamela Blondin, whose
husband is being treated daily for colitis. (Photo by Rick M. Scibelli for USA
Today)

"Would
you rather stay home or go to the hospital?" she asked Frank Blondin, 52,
who suffers from severe rheumatoid
arthritis and heart disease, and had a nasty diarrhea-inducing
bacterial infection.

"Home,"
Blondin responded, without hesitation.

Soon,
the doctor was managing a "hospital at home" admission for Blondin —
an arrangement allowing him to receive intensive care and medical monitoring in
the quiet of his own bedroom. Medical supplies and medications would be
delivered as soon as possible, she told Blondin's wife, Pamela. A
nurse would come within the hour, take laboratory samples, and return later
that afternoon and in the days to come. Ward would check in by phone,
visit daily, and help would be available 24/7 if required.

"Hospital
at home" programs fundamentally refashion care for chronically ill
patients who have acute medical problems — testing traditional
notions of how services should be delivered when people become seriously
ill. Only a handful of such initiatives exist, including the
Albuquerque program, run by Presbyterian Healthcare Services, and programs in
Portland, Ore., Honolulu, Boise, Idaho, and New Orleans offered through the
Veterans Health Administration.

But
the concept – which has been adopted in Australia, England, Israel
and Canada — is getting attention here with increased pressure from
the national health overhaul to improve the quality of medical care and lower
costs. Hospital at home programs do both, according to research led by Dr. Bruce Leff, the director of
geriatric health services research at Johns Hopkins School of Medicine in
Baltimore who pioneered the concept.

In
a study of
three experimental hospital at home programs published in 2005 in the
Annals of Internal Medicine, Leff demonstrated that patient outcomes were
similar or better, satisfaction was higher and costs were 32 percent less than
for traditional hospitalizations.

The
initial programs focused on people with four conditions — chronic
obstructive pulmonary disease, congestive heart failure, pneumonia and skin
infections known as cellulitis. Presbyterian Healthcare has expanded the list
to include patients with dehydration, nausea, urinary tract infections, blood
clots, and some artery blockages in the lungs.

Excluded
are patients who are medically unstable or who cannot be cared for adequately
at home. "The patient, the family, the nurse, the doctor and the
referring physician all need to feel if it's safe," said Dr. Scott Mader,
clinical director of rehabilitation and long-term care at the Portland VA
Medical Center, which recently treated its 1,000th
hospital at home patient. If patients take a turn for the worse, for instance
developing chest pain, an ambulance is summoned to take them to the hospital.

'It's
Going To Be Very Common'

In
most programs, doctors examine the patient daily and nurses and aides come up
to three times a day, often for an extended period. Patients are
admitted for three to five days after being seen in the emergency room,
referred by a physician or discharged early from a hospital.

Last
year, the Cochrane Collaboration, an international organization that evaluates
the evidence supporting health care interventions, published a review of 10 randomized controlled
studies on hospital at home programs; it found that 38 percent fewer
patients in these programs had died after six months, compared to those who
underwent traditional hospitalizations.

"Imagine
if there was a pill that did that: everyone would want it," Leff
said.

"It's
a very successful model and in five years, I think it's going to be very
common. But we're still in the early adoption phase," said Mark
McClelland, an assistant professor at the Center for Health Care Quality at
George Washington University.

Among
current plans for hospital at home programs:

Presbyterian
Healthcare and McClelland's center have applied for a Medicare "innovation" grant to
bring hospital at home programs to sites in Illinois, Rhode Island, New York,
Florida and Minnesota.

The
Veterans Health Administration has approved funding for a new hospital at home
program in Philadelphia and an expanded program in Honolulu, said Kenneth Shay,
director of geriatric programs for the VHA. "This is a very
patient-centered model of care that also has the potential to reduce rates of
hospital-related complications" such as infections, medication mix-ups,
and delirium, Shay said.

Clinically Home, a commercial
venture, has developed a hospital at home model that involves caring for
patients over 35 days, combining acute and post-acute care.
Kaleida Health, the largest health care system in western New York, wants to
sign on to start a program later this year – if it can convince local
insurers to come on board, said Donald Boyd, senior vice president.

Resistance
from Medicare and private insurers is the biggest problem these programs
face. Traditional fee-for-service Medicare does not pay for hospital
at home services, although individual private Medicare Advantage plans may do
so. The Centers for Medicare and Medicaid Services "appears
convinced it's going to add to overall costs" and fearful that providers
will admit patients inappropriately, said Erin Denholm, chief executive of
Centura Health at Home, a division of Colorado’s Centura
Health.

For
physicians, "doing hospital-level services at home sounds scary" and
"it's a big jump" that they haven’t yet embraced, said
McClelland. Starting a program requires a considerable up-front
investment of time and money, and it's not a priority for many institutions
distracted by the pressures of the national health overhaul, he said.
Indeed, keeping beds full is a financial mandate for most hospitals.

That
may change as hospitals and doctors form new structures known as
"accountable care organizations (ACOs)" that are promoted in the
health care overhaul. ACOs call for providers to restructure how medical care
is delivered while participating in the financial rewards and risks of those
changes.

Presbyterian
Healthcare in Albuquerque is New Mexico's largest health care system, including
eight hospitals, 36 clinics, a large physician group, five home health care
agencies, and its own 413,000 member health plan.

Because
Presbyterian has control over how that health plan pays for services, it was
able to start a hospital at home program in 2008 with a reliable funding base.
As for the motivation, "We are never going to build enough bricks and
mortar (institutions) to provide care for all the baby boomers and the elderly
who will need it by 2030," said Lesley Cryer, executive director of
Presbyterian Home Healthcare. "So, we've got to find alternatives like
this."

Patients
Appreciate Being Home

On
a recent morning in Albuquerque, Dr. Melanie Van Amsterdam, one of three
doctors who provide hospital at home care for Presbyterian, stopped in to see
Rosa Sota, 76, who had fallen on a doorstep, cut herself above her right
eyebrow, and developed cellulitis.

Van
Amsterdam set a chair in front of the older woman, who was lying on a couch in
her small living room with a pinched expression. The doctor did a
careful examination, then explained the course of treatment she was
ordering.

Rosa
Soto receives interveinous antibiotics at her home from Darren Maestas, patient
care manager with Presbyterian Healthcare System's Hospital at Home program.
(Photo by Rick M. Scibelli for USA Today)

"It's
better in my house because if I need to eat, I don't have to push a button. I
can go to the kitchen for myself," Sota said, as her husband Ruben nodded
in agreement a few feet away. "And here I sleep better because you don't
have all the people coming and going and I don't feel so nervous."

For
Frank Blondin, care began with a call for help from a home health nurse. Within
an hour, Ward arrived, performed a thorough evaluation, obtained the patient's
consent for a hospital at home admission, and decided on a treatment for his
main medical issues — dehydration and the infection. Then, Ward sat
down to carefully review Blondin's history and medications with his wife and
explain that risks were slightly higher that complications would not be dealt
with as quickly as in the hospital.

"Is
that OK by you?" the doctor asked.

"I'm
a little apprehensive because I've had to call 911 so many times for
Frank," Pamela Blondin admitted. "But he really wants to be home and
I'd much rather have him here. Even though there's a bit of a fear
factor, I have to tell you, I appreciate having the choice."

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